Effects of Volatile Versus Intravenous Anesthesia on Cerebral Vasospasm in Open Surgical and Endovascular Procedures for Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis.

The selection of anesthetic agents during aneurysm repair may have an impact on the prognosis of patients with aneurysmal subarachnoid hemorrhage (SAH). In this systematic review and meta-analysis, we compared the effects of volatile-based anesthesia with those of total intravenous anesthesia (TIVA) on perioperative outcomes in SAH patients. A comprehensive literature search was performed in PubMed, EMBASE, Web of Science, and the Cochrane Library through December 2024, yielding 9 studies (comprising 4 randomized controlled trials [RCTs] and 5 cohort studies) with a total of 1459 participants. Data pooled from the cohort studies indicated that volatile-based anesthesia was associated with a lower risk of postoperative cerebral vasospasm (risk ratio [RR]=0.72; 95% CI: 0.62-0.83; I2 =22%) and delayed cerebral ischemia (RR=0.63; 95% CI: 0.51-0.80; I2 =22%). In contrast, analyses of the RCTs showed no significant differences between the 2 anesthetic techniques regarding cerebral vasospasm (RR=1.04; 95% CI: 0.35-3.06; I2 =60%), infarction (RR=1.51; 95% CI: 0.76-3.00; I2 =0%), or intraoperative brain swelling (RR=1.14; 95% CI: 0.83-1.58; I2 =0%). The Egger regression test did not reveal any evidence of publication bias. Overall, these findings suggest that although cohort studies point to a potential benefit of volatile-based anesthesia in reducing the incidence of postoperative vasospasm and delayed cerebral ischemia, the pooled results from RCTs do not corroborate these differences. Thus, further large-scale, high-quality randomized trials are warranted to better elucidate the comparative effects of these anesthetic approaches in aneurysmal SAH repair procedures.